COPING WITH THE UNCERTAINTIES OF SEIZURES AND EPILEPSY: SPASTIC HEMIPARESISA spastic hemiparesis is a form of cerebral palsy that affects only one side of the body. It is caused by damage in the opposite side of the brain by a stroke, bleeding into the brain, trauma, or a problem in the brain’s development. The arm is usually more affected than the leg; there may be major problems with the use of the hand. Such children will usually be able to learn to walk with a limp. Since the damage is focal (onesided), these individuals are less likely to have mental retardation. Although we do not understand all of the factors that cause one person’s damaged brain to provoke seizures while another’s does not, and cannot predict which child will have seizures and which will not, in general we do know that a child with a hemiparesis whose CT or MRI scan shows brain damage is more likely to have seizures than one who does not have these problems. We treat the seizures as we do other focal seizures. Unlike the child with a spastic quadraparesis, the child with a hemiparesis may be a candidate for focal epilepsy surgery to remove the damaged tissue causing the seizures if they are uncontrollable.*199\208\8*
HIGH BLOOD PRESSURE AND NUTRITIONAL SUPPLEMENTSOne of the most important things you can do for your overall health is to take nutritional supplements. A study published in the Western Journal of Medicine in 1997 examined the potential benefits of just three nutritional supplements: vitamin E, folic acid, and zinc. The researchers calculated that if every American in targeted groups took these supplements, there would be a net reduction in health care costs of almost 20 billion dollars per year. According to this study, if everyone over 50 years of age took vitamin E, hospital costs associated with heart disease would be reduced by 38 percent. If women of childbearing age took folic acid, the hospital costs of caring for children born with neural tube birth defects would be lowered by 40 percent, and if these same women took zinc, the costs of caring for low-birth-weight babies would drop by 60 percent. Imagine, a savings of 20 billion dollars simply by taking three supplements! And just think about the human suffering that would be avoided.Don’t underestimate the power of targeted nutritional supplements. If the systems in your body involved in regulating blood pressure, beginning at the cellular level, do not receive the raw materials they need to function and regenerate, the entire works go awry. Hypertension is caused in part by deficiencies and imbalances of certain nutrients. One of the very first steps you should take toward lowering your blood pressure is to implement the suggestions for supplementation. It is a cornerstone of this program for reversing hypertension.*73/313/5*
HIV: ON LIVING-TAKING CONTROL: GIVE YOUR FEELINGS THEIR DUEWhen you feel bad, go ahead and feel that way. Tell yourself, as Dean does, “I’m just tired of this. I don’t see how I can do it any more.” Cry, stare into space, refuse to talk, stay in bed, write your terrible feelings in a private journal—go off by yourself and do whatever expresses the bad feelings. “I don’t believe in this crap of, ‘You’ve got to be happy all the time,’ ” says Steven. “I’m not taped together as well as I thought I was, or more likely, the tape was old. Anyway, sometimes I fall apart and just feel awful.” In short, give your feelings their due. This is not giving in. It is acknowledging the reality and size of the problems you face. Somehow, such acknowledgment is easier than trying to control how you feel, or going from crisis to crisis and never feeling anything. These feelings, once acknowledged, don’t last as long as you might think. They seem to wear themselves out and disappear. “After I’ve been feeling hopeless for a while,” says Dean, “the feeling lightens up, and I feel that I’ve really got a long road ahead of me. I’ve seen too many people give up. I feel like I’d just like to keep going.” The feelings will certainly come back again—Steven says he now knows when he is likely to feel bad and sets aside time for the feelings: “I plan for falling apart,” he says. But when the feelings do come back, you will have them in better perspective. That is, you will know that the feelings are both real and temporary. For good reasons, you feel bad; and after a while, for reasons just as good, you will feel better.*239\191\2*
CLINICAL MANIFESTATIONS OF ANTHRAXThere are three main types of anthrax infection:Cutaneous anthraxCutaneous anthrax results from direct contact with the microbe on the skin or mucous membranes. More than 95% of naturally occurring anthrax is the cutaneous form. Approximately 1 to 7 days after anthrax endospores are introduced into the skin at a site of a previous cut or abrasion, a painless, pruritic macule or papule appears. Within 24 to 36 hours, the lesion forms a vesicle filled with clear or serosanguinous fluid containing numerous organisms that can be seen with Gram stain. The lesion undergoes necrosis, forming a painless ulcer covered by a characteristic central black eschar. There is accompanying non-pitting edema, which may be extensive, and multiple bullae may occasionally develop. Low-grade fever and malaise may be present, and painful regional lymphadenopathy can occur. Incision and debridement of early lesions should be avoided, since this may increase the chance of bacteremia. The eschar dries and falls off in 1 to 2 weeks, often with no residual scarring. The administration of antibiotics does not change the course of eschar formation but does decrease the likelihood of systemic disease. Although bacteremia is rare, the mortality rate has been reported to be as high as 20% without antibiotics but is less than 1 % with them.
Inhalational anthraxInhalational anthrax follows deposition of endospores into the alveolar spaces and may be a biphasic illness. The minimum infectious inhaled dose has not been precisely determined. Symptoms can develop 2 to 60 days after the inhalation of spores but usually develop after 6 days of incubation. The early phase is characterized by the insidious onset of fever, malaise, nonproductive cough, and dyspnea. Nausea, vomiting, and abdominal pain may also be present. Pleuritic chest pain and drenching sweats were prominent features in the 2001 U.S. anthrax outbreak. This stage of illness lasts from hours to a few days. Some patients may experience a brief period of apparent recovery. However, a second phase begins abruptly with spiking fevers, worsening dyspnea, and hypotension. A widened mediastinum due to massive mediastinal lymphadenopathy may be identified on chest radiograph. Pleural effusions may also be evident. These enlarged nodes can lead to partial tracheal compression and stridor. Up to one half of patients develop hemorrhagic meningitis with subsequent coma. Death can occur within hours. The mortality rate was previously reported to approach 90%, but in the recent U.S. anthrax bioterrorist cases, lower mortality rates (approximately 40%) were observed.
Gastrointestinal anthraxGastrointestinal anthrax can occur following the deposition of endospores in the upper or lower gastrointestinal tract. It is presumed that endospores inoculate areas of mucosal breakdown. This form of anthrax has never been reported in the United States. Symptoms can appear 2 to 5 days after the ingestion of endospore-contaminated meat. If spores are deposited in the oropharyngeal region, clinical findings typically include oral or esophageal ulceration accompanied by cervical edema and lymphadenopathy. Patients may complain of dysphagia, nausea, vomiting, fever, and even respiratory difficulty. Lesions have the appearance of pseudomembranous ulceration. If endospores are deposited in the lower gastrointestinal tract, patients may present with nausea, abdominal pain, fever, and bloody diarrhea. Hemorrhagic mesenteric lymphadenitis and massive ascites can also occur. Death occurs from intestinal perforation and anthrax toxemia. The case-fatality rate of gastrointestinal anthrax ranges from 12% to 50%.*207/348/5*
COGNITIVE-BEHAVIORAL THERAPY FOR BDD: COGNITIVE RESTRUCTURING (COGNITIVE THERAPY) - IT CAN ALSO HELP TO DO COGNITIVE RESTRUCTURING BEFORE, DURING, AND AFTER THE EXPOSURE This can help you get your thinking straight before you go into the anxiety-provoking situation. You can also do cognitive restructuring during the exposure, while you’re actually in the situation, by identifying your cognitive errors and thinking alternative, more realistic thoughts. Filling out a thought record after the exposure may also be helpful, especially if the situation made you very nervous. This can help you reappraise what happened in a more accurate way.If exposure therapy is too anxiety provoking, move back down to a lower-rated activity on your hierarchy. If this, too, is too anxiety provoking, you may need to modify the hierarchy, so less anxiety-provoking situations are included. Sometimes the SUDS levels need to be reevaluated and modified because you may underestimate the actual anxiety level you’ll experience in the situation. The important thing is not to give up! If you do it right, exposure will make you somewhat anxious, but the more you do it, the easier it will get. And the rewards can be enormous: you’ll be able to live a much freer and more enjoyable life.*322\204\8*
THE EVOLUTION OF INSOMNIA DRUG THERAPYFor the first half of this century, barbiturates were the only pharmacological option available for insomnia. Veronal, the first barbiturate, was introduced in 1903. In the years following, about fifty drugs of this class reached the market (out of nearly twenty-five hundred barbiturate compounds developed in the lab). However, barbiturates were found to have two dangerous drawbacks: a high potential for addiction and a great risk of lethal overdose. Today only a dozen or so are still available; those used primarily for sleep are secobarbital (Seconal), amobarbital (combined with secobarbital in a product called Tuinal), and pentobarbital (Nembutal). Other uses for barbiturates are as antianxiety agents, anesthetics, and anticonvulsants.In the late 1950s tricyclic antidepressants came on the market. In addition to their effect on serious depression, some of these drugs also possess sedative effects, although just how they work is not completely understood. Antidepressants offered an alternative to the potential dangers of barbiturates, but they too have undesirable side effects. While not considered the drug of first choice today, antidepressants may be used to alleviate insomnia—especially if the insomnia is associated with depression.A major breakthrough in the drug treatment of insomnia was achieved with the arrival of benzodiazepines in the early 1960s. Compared to their prescription drug predecessors, benzodiazepines—primarily flurazepam, temazepam, and triazolam—have a greatly improved safety profile and are much more effective, particularly in disorders of initiating and maintaining sleep in individuals whose insomnia lacks an identifiable physical cause. Their improved ratio of therapeutic dose to lethal dose means a much lower risk of abuse or dangerous adverse effects. Some research does indicate, however, that there is a potential for addiction in patients taking the drugs over long periods of time. Benzodiazepines fall into several subcategories, usually depending on how quickly and for how long the drug works.Of course, there are also several nonprescription sleeping aids available (brand names include Nytol, Sominex, and Sleep-Eze).In all of these the active ingredient is the same: diphenhydramine, a form of antihistamine. As you may know, antihistamines are used to dry up secretions in the eyes, nose, and throat, thus relieving some symptoms of colds and allergies. The drowsiness caused by antihistamines is really only a side effect; makers of over-the-counter sleeping aids have thus taken a drug liability and marketed it as an asset. Antihistamines may prove especially useful in the treatment of insomnia complicated by a history of drug or alcohol abuse, since they do not have the potential for abuse that is associated with other drug therapies (such as benzodiazepines and barbiturates).*270\226\8*
HIV: ON LIVING-TAKING CONTROL: CONFRONT THE POSSIBILITIES A LITTLE AT A TIMEOnce, when Dean Lombard was in the hospital, he “roomed for a while with a man who was in the advanced stages of AIDS. “I was glad to get out of that room,” Dean said. “As long as I was there, I needed to confront the possibility that what happened to him would happen to me. But confronting that possibility seemed necessary, to deal with this disease as positively as I am.” Confronting the possibilities means, for Dean and others like him, understanding and admitting that the fact of HIV infection cannot be annulled. Steven said, “I have to deal with this whether I want to or not.” It is now a part of life. So are the possibilities of fatigue, disability, dependency, illness, clinic appointments, and hospitalizations. And so are the emotional reactions to all this. “HIV makes me face things I didn’t think I’d have to face,” Helen said. Confronting the facts and possibilities and reactions is often the only way through them. Confronting everything all at once, however, is overwhelming and unnecessary. Face what you are ready to face, and only when you are ready. When you are tired of thinking or feeling, stop and rest. Do not push yourself because you or someone else thinks you ought to be facing things. Face a little at a time. In fact, confronting the facts means facing not only sickness but also health. If, within some amount of time, fatigue, death, or dependency are possibilities, so are strength, life, and confidence. People remind themselves that no one knows with certainty how the disease progresses in every individual.*244\191\2*
Chlamydiae are sensitive to various antibiotics including tetracycline and erythromycin. Tetracyclines are also effective against mycoplasmal infections. No effective single dose treatment is available. Penicillins and other beta lactams are ineffective. Standard practice is to treat patients on the demonstration of cervicitis or urethritis or on the basis of a contact history.
Patients should avoid sexual intercourse until treatment is completed. The importance of compliance with treatment should be stressed.
The recommended treatment for NGU or NGC is a tetracycline (e.g. doxycycline 100 mg twice daily taken with food or milk for 10 days). Regimens for treatment of PID are detailed on pp. 14-15. The sequelae of these infections can be serious and treatment should not be delayed until laboratory investigations are complete.
Tetracyclines are contraindicated in pregnancy and children of 8 years of age or less.
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The diagnosis of chlamydia is commonly presumptive but should be confirmed using laboratory tests. Direct detection using commercially available immunofluorescence or ELISA monoclonal antibody techniques permits rapid diagnosis. False positive and negative results occur; false positive results can be a problem, particularly in patients who deny risk of sexually transmitted infection. Results must be interpreted having regard to the clinical context
Chlamydiae are obligate intracellular parasites; isolation requires tissue culture techniques and takes 3 or 4 days. Direct tests are not as sensitive as culture but are reliable and much less expensive. Culture is only available from a few laboratories.
Serology is of limited value. Complement fixation tests for antibody are not very specific and have largely been superseded. ELISA and immunofluorescence techniques detect chlamydial group antibodies. Microimmunofluorescence tests can detect type specific antibodies. Seroconversion or a 4-fold increase in titre in serum samples collected 2 weeks apart indicates acute infection. A high titre of IgG antibodies and the presence of IgM antibodies probably indicate current infection. Negative serology may be of value in excluding chlamydial infectioa
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In our eagerness to correct the old misconceptions, we do need to be wary of falling into the trap of replacing one assumption with another — that all older people want to continue to be sexually active and that every one of us will have sexual needs until the day we die. One thing is true. We are all individuals. Some people will keep their interest in sex as they get older, but there are others who are quite happy to lose the urge as other aspects of their lives take precedence. Of course there are still others who never liked it much anyway and that’s not likely to change.
What might change is the way you want to express your sexual feelings. Harold is in his sixties. He explains, ‘In many respects the peaks of intense sexual feelings are not as keen as in my younger years and I’ve certainly slowed up. Although I still have orgasms, touching, companionship and just being close have become much more important than in my youth.’
One of the inevitabilities of growing old is the prospect of separation from your partner because of illness or death. Losing the person who has shared your most intimate moments is devastating. If you ask someone who is recently widowed what they miss the most, it’s often the little things like the Sunday morning cup of tea, or curling up on the lounge to watch television, asking their opinion on a flower arrangement or tucking up in bed together on a stormy night.
Molly, widowed at fifty-two, and now in her seventies frankly says, ‘I’d vomit if another man touched me. When I was young I was brought up to believe that you had one partner for life arid if anything happened to him that was the end of your sex life for good. You just can’t change the sort of ingrained idea that it would be somehow unfaithful to his memory to start seeing someone else. My friends tried to match-make me with any Tom, Dick or Harry but I just wasn’t interested. I found the most difficult time to cope was in bed at night. I would just miss knowing he was lying next to me in the bed. Sometimes even now I wake up and think I can hear him breathing. I was grieving so much at the time that sex was the last thing on my mind. When I started getting over the grief I never seemed to get my interest back. When I get miserable I get by with a hot bath and putting lots of pillows in the bed. I get a lot of affection and love from my daughter and my grandchildren.’